MEDICARE: MS. CHRISTINE ADRIENNE FISH PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	01033	IA
2	225200000X	Physical Therapy Assistant		IL

General Provider Information

NPI Number	:	1639358419
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CHRISTINE ADRIENNE FISH PTA

Provider Business Mailing Address
First Line	:	5403 VICTORIA AVE
Second Line	:
City	:	DAVENPORT
State	:	IA
Zip	:	52807-3925
Country	:	US
Telephone Number	:	563-327-0132
Fax Number	:

Provider Business Practice Location Address
First Line	:	2500 GRANT ST
Second Line	:
City	:	BETTENDORF
State	:	IA
Zip	:	52722-5092
Country	:	US
Telephone Number	:	563-359-9171
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/30/2007
Last Update Date	:	10/30/2007

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